Table 2.

Key Strategies for Improving Care for Low Back Pain^*

Preoffice Visit

♦ Public service announcements, newsletters, or standardized educational material available to patients prior to acute episode to minimize expectations of x-rays, imaging, and bed rest (1)

♦ Dedicated phone number for access to triage nurse or other provider (6)

– With patient agreement, an informative wait inserted before appointment is made

– Recommended self-management techniques and symptom relief offered to patient

– Patient provided with information on usual course of treatment prior to visit

At the Time of Care

♦ Physician uses patient history and brief physical examination to rule out serious underlying disease (9)

♦ Imaging and surgical referrals made only when appropriate:

– Number of views for plain x-rays is limited by protocol (e.g., eliminating obliques and coned lateral) (4)

– Informative wait before ordering tests or making referral (6)

– Telephone consultations with surgical and nonsurgical specialists readily available to primary care physician (6)

– Imaging and referral utilization data provided and reviewed with physician, including comparisons with peers or with guidelines (13)

– New options to refer appropriate patients to nonsurgical specialists: spine center, physical therapist, physiatrist, support/educational group or other sources for patients who do not improve within 4-6 weeks, yet have no surgical indications (1)

♦ Patient interaction guides (script, checkoff list) and standardized patient educational material to counsel patient on recommended course of treatment and self-management techniques (6)

♦ “Outlier” rates of imaging or referral used to identify clinics or physicians for targeted intervention (1)

♦ Decision aids (laminated cards, computer reminders, check lists) to reinforce indications for imaging or surgical consultation (4)

♦ “Academic detailing” (1-on-1 advising with eye-catching handouts) to introduce key guidelines, provide rationale, and references (5)

♦ Influential peers involved in developing or adapting guidelines, decision aids, patient education materials, and detailing materials (11)

♦ Multidisciplinary review conference for planned surgical cases (1)

To Accelerate Return to Work

Providers and employers

♦ Agree on standard treatment protocols, reporting forms, and return-to-work procedures (4)

♦ Consider detailing sheet to educate patients and employers (0)

♦ Identify key points of contact at both physician's office and corporate site (4)

Employers

♦ Institute transitional return-to-work policies and provide flexibility in job assignments (2)

♦ Provide time during day for recommended exercise and rehabilitation (0)

♦ Call patients to express concern, enthusiasm for early return to job (0)

Providers

♦ Reduce prescriptions for bed rest and time off (10)

♦ Avoid unnecessary x-rays and imaging (8)

♦ Prescribe return to normal activities, appropriate exercise (part of patient education efforts)

♦ Visit employers to build communication and provide education (1)

^*Approximate number of plans attempting each strategy is shown in parentheses.